Cases & Commentaries

An elderly woman presented to the emergency department following a hip fracture. Although the patient's medication bottles were used to generate a medication list, one of the dosages was transcribed incorrectly. Because the patient then received four times her regular dose, her surgery was delayed due to cardiac side effects.

Journal Article > Study

The authors analyzed reports of drug administration errors by nursing students. They found that omission errors were most common and that student inexperience and distraction were contributing factors.

Journal Article > Study

The investigators used a simulated scenario to analyze communication problems among nursing teams that led to medication errors. They discuss the differences between student and nurse groups, concluding that as service years increase, nurses are less likely to explain and confirm medication requests.

Journal Article > Study

This qualitative study examines how the advent of information technology has influenced nursing communication with pharmacists, and discusses how prescribing systems should be structured to account for these factors.

Journal Article > Study

In this study, nurses at a Veterans Affairs hospital were surveyed regarding their experiences with medication errors and their perception of the effect of computerized physician order entry (CPOE) and bar code medication administration (BCMA) on the incidence of errors. Nurses identified many reasons for medication errors, including fatigue and illegible physician handwriting. While most nurses had filed an incident report due to a medication error, the majority agreed that some errors go unreported due to fear of criticism from management or colleagues. The implementation of CPOE and BCMA was associated with a lower perceived incidence of errors.

Special or Theme Issue

This issue covers a variety of topics related to quality and safety education for nurses, including the integration of safety content into daily work and an assessment of available educational opportunities.

Measures that have been proposed to reduce the incidence of medication errors target prescribing safety (e.g., computerized provider order entry) or safety in administering medications (e.g., bar coding or automated dispensing). While each of these individual measures has been shown to decrease errors, as yet few systems "close the loop" by integrating safety measures for prescribing and administering medications. Utilizing an electronic system that incorporated CPOE, automated dispensing, bar coding, and an electronic medication record, this single-institution study demonstrated a significant reduction in both prescribing errors and administration errors. However, staff time spent on medication-related tasks increased. While the study results are promising, one caveat is that the system was not used for high-risk drugs such as anticoagulants or intravenous medications.

A continuous physiologic monitoring system appeared to detect physiologic instability earlier than standard monitoring techniques. Prior research has questioned the false negative rate of such systems, but that problem was not noted in this study.

Journal Article > Review

A 2008 Joint Commission Sentinel Event Alert highlighted the increased risk of medication errors in children, who are particularly vulnerable due to specialized dosing needs that may require calculations by nurses or pharmacists. This review sought to evaluate the connection between calculation errors and actual medication errors, but found that while some studies have examined the incidence of calculation errors and methods of preventing these errors, few studies have specifically measured the effect of calculation errors on patient outcomes (and no studies have been performed in pediatric hospitals). Computerized provider order entry holds promise as a way of preventing adverse drug events due to calculation errors.

Computerized provider order entry is usually considered to be synonymous with computerized physician order entry. However, in this Iranian study, having nurses enter medication orders (which physicians subsequently countersigned) resulted in significantly fewer medication errors.